Tranexamic Acid (TXA)
Tranexamic acid is a synthetic form of lysine, an amino acid. It binds to receptors on plasmin preventing it from breaking down fibrin clots. The drug has been studied in many settings for the prevention or treatment of hemorrhage. The uses most relevant to emergency medicine (EM) include traumatic hemorrhage, gynecological hemorrhage, and epistaxis, summarized below.
Please note that the vast majority of these indications are not currently approved by the U.S. Food and Drug Administration (FDA).
Menorrhagia: brandname Lysteda, 1,300 mg PO TID during menses, max 5 days
Off Label Dosing
- Epistaxis treatment using injectable form of TXA topically 
- 500 mg in 5 ml of TXA soaked into a cotton pledget was superior to anterior nasal packing
- Absolute risk reduction 40%, NNT 2.5
- Small study, only 216 patients
- Postpartum hemorrhage: 1,000 mg IV over 10 minutes given within 3 hours of vaginal birth or cesarean section
- If bleeding continues after 30 minutes or restarts within 24 hours after the first dose, a second dose of 1,000 mg may be given 
- Trauma-associated hemorrhage: IV Loading dose 1,000 mg over 10 minutes, followed by 1,000 mg over the next 8 hours 
See www.admin-em.com for a deep dive into the primary evidence.
- Zahed R, Moharamzadeh P, Alizadeharasi S, Ghasemi A, Saeedi M. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med. 2013;31(9):1389-92. [PubMed]
- WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017;389(10084):2105-2116. [PubMed]
- Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376(9734):23-32. [PubMed]
- Roberts I, Shakur H, Afolabi A, et al. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet. 2011;377(9771):1096-101, 1101.e1-2. [PubMed]
- Ker K, Roberts I, Shakur H, Coats TJ. Antifibrinolytic drugs for acute traumatic injury. Cochrane Database Syst Rev. 2015;(5):CD004896. [PubMed]
- Wafaisade A, Lefering R, Bouillon B, et al. Prehospital administration of tranexamic acid in trauma patients. Crit Care. 2016;20(1):143. [PubMed]
- Ausset S, Glassberg E, Nadler R, et al. Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting: A critical appraisal of the medical literature and available alternatives. J Trauma Acute Care Surg. 2015;78(6 Suppl 1):S70-5. [PubMed]
- Gayet-ageron A, Prieto-merino D, Ker K, et al. Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40 138 bleeding patients. Lancet. 2017. [PubMed]